Trying to Make a Difference: A Critical Analysis of Health Care during Pregnancy for Aboriginal and Torres Strait Islander Women

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Abstract: This paper critically examines pregnancy health care and services for Aboriginal and Torres Strait Islander women, to explore the question of what might 'make a difference'. More antenatal care, and in particular Aboriginal women attending for care earlier and more often, is often put forward as what is needed to improve pregnancy outcomes, as well as the health of future populations. However, evidence from epidemiological, clinical and health services research problematises this assertion. An alternative and preferable driver for the reform of maternity services for Aboriginal women would be to allow women themselves to have more say in decision making at both individual and institutional levels.

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Aboriginal and Torres Strait Islander women experience a greater frequency of adverse pregnancy outcomes than other Australian women, and this has been documented for years (Day et al. 1999; Plunkett et al. 1996). Health care during pregnancy aims to improve the health and wellbeing of women and their babies. However, the capacity of such care to improve the pregnancy outcomes of Aboriginal women has rarely been investigated systematically, or at all. (1) A critical exploration of antenatal care and maternity services is useful to inform changes to policy and practice that will 'make a difference' to the health of pregnant Aboriginal women and their babies.

Here I draw on several literature-based and data-based research projects that I undertook between 1999 and 2003 while completing doctoral studies (Hunt 2003). These studies followed several years' work as a clinical and public health doctor in Aboriginal Community Controlled Health Services in Darwin and elsewhere. During this time I had a particular interest in Aboriginal women's health, including the care of women during pregnancy.

Antenatal care--a selective history

In countries like Australia, health care during pregnancy has been institutionalised since the early 1900s. Initially, medical care during pregnancy was promoted as a way of improving the health of populations; it was considered that 'medical supervision' could have a positive impact on infant and maternal mortality (Campbell 1930). In at least some cases, this belief in the positive effects of medical care turned out to be unsupported by subsequently available evidence. Loudon's (1992) review of historical trends in maternal mortality demonstrated that, in the days before antibiotics, being attended by an obstetrician increased a woman's chance of dying of puerperal fever. Later epidemiological studies suggested that doctors were spreading infection through bacterial carriage.

Antenatal care has generally included various screening activities to check on the health of mother and baby during pregnancy as well as interventions aimed to improve health and wellbeing. An increasing number of tests and procedures have been added to what has been considered routine in antenatal care. While there are many examples of innovations with positive health impacts, the history of antenatal care also includes some cautionary tales, including examples of tests being adopted without their safety being assessed adequately. For example, X-rays were used to diagnose or exclude pregnancy and to assess gestation from the time of their invention in the 1900s until the 1950s when ultrasound took over as a way of visualising babies in utero, despite accumulating evidence of their role in causing childhood cancer (Oakley 1984).

It seems unlikely that antenatal care technologies introduced in more recent times will have as dramatically adverse impacts on the health of women and babies as X-rays turned out to have. Since the 1970s the 'evidence-based' medicine and consumer health movements have been instrumental in stressing the importance of new and existing medical technologies being better evaluated before being adopted (Cochrane 1972). (2) However, many tests and procedures used in clinical practice have not been subjected to rigorous evaluation. …